Soft tissue reconstruction in patient’s with renal disease can pose great challenges to the reconstructive microsurgeon. We preformed a retrospective analysis of all patients who underwent free tissue transfer with concomitant renal disease to determine what effect renal disease has on flap survival and reconstructive success. A retrospective analysis was preformed on free tissue transfers preformed between January 1991 and August 2000. All patients with a history of renal insufficiency, (creatine > 1.6 mg/dL), renal failure requiring dialysis, and functional renal transplants were included in the study. Patient’s charts were examined and phone interviews were conducted to determine post-operative course. 1053 free flaps were examined. Renal disease was identified in 32 patients who underwent 33 free flaps. Average patient age was 57. 28 flaps were preformed for complications of limb threatening ischemia, 4 were for tumor reconstruction and one was for trauma. 12 patients were on chronic dialysis (ESRD), 15 patients had renal insufficiency (CRI), 3 had the diagnosis of ARF at the time of surgery. 3 patients had a functioning renal transplant. 25 patients had peripheral vascular disease, 28 suffered from diabetes. 19 patients underwent a concomitant vascular bypass procedure at the time of free tissue transfer. Average follow-up was 19 months. Immediate post-operative complications occurred in 12 patients (36%). Overall peri-operative mortality was 3%. Within the first thirty days there were only 2 cases of primary flap loss. 2 lower extremities were amputated because of vascular complications: 1 due to hemorrhage and 1 due to vascular bypass ligation. This resulted in a total of 5 early reconstructive failures (15%). There were no primary flap failures after 30 days, however, within the first year following surgery an additional 6 limbs were lost due to progressive ischemia or infection, and an additional 5 patients died. This resulted in a 67% incidence of major morbidity or mortality occurring in the first post-operative year, and a 52% reconstructive success rate at one year. No significant difference was seen in post-operative morbidity or mortality when comparing the ESRD group to the CRI group. 64% of patients with diabetes experienced a post-operative complication at one year compared to 20% of non-diabetic patients. Renal disease, especially renal disease associated with diabetes and critical lower limb ischemia should be a strong indicator of possible reconstructive failure. Surgeon and patient should be aware of the medical and surgical complications of this procedure prior to outset.